Case Report Veterinarni Medicina, 63, 2018 (04): 198–202

https://doi.org/10.17221/8/2018-VETMED

An unusual foreign body in a cat: a case report

C.F.R. Agudelo1*, Z. Filipejova1, L. Frgelecova2, O. Sychra3 1Faculty of Veterinary Medicine, Small Clinic, University of Veterinary and Pharmaceutical Sciences Brno, Brno, 2Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic 3Faculty of Veterinary Hygiene and Ecology, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic *Corresponding author: [email protected]

ABSTRACT: Foreign bodies that affect airways are a well-recognised problem in small-animal practice. Cats in par­ticular, may be especially at risk of aspiration due to their predatory behaviour. Here, we report a case of an as a foreign body, namely a in the tracheal bifurcation of a cat. Radiographs suggested a wide range of possibilities for differential diagnosis, but the presence of a foreign body was initially suspected. A final diagnosis was not pursued by the owner and the cat was euthanised. The presence of a summer chafer was then confirmed. To the authors’ knowledge, this is the first time such a foreign body and radiographic findings are reported in the literature.

Keywords: aspiration; beetle; dyspnoea; summer chafer

Any materials of relative small size, which en- Dogs and cats recovering from anaesthesia may ter into the airways by inhalation and cannot be bite endotracheal tubes and small portions may eliminated by conventional methods like sneez- stay in the tracheal lumen (Nutt et al. 2014). A ing, coughs, gagging, etc., present as respiratory meta-analysis of aspirated foreign bodies in cats foreign bodies. Foreign bodies in the airways are described needles, a safety pin, wood mulch, a commonly found in the nasal cavity, nasophar- tooth, gravel, bone and a bullet (Tivers and Moore ynx, larynx, trachea and bronchi. Although most 2006). Clinical symptoms associated with airway foreign particles enter the airways from outside, obstruction include sudden onset of dyspnoea regurgitation or vomiting can also lead to aspira- with coughing, retching or gagging (Levitt et al. tion resulting in complicated pneumonia or bron- 1993). Some episodes may conclude with fatal chopneumonitis. Foreign bodies such as needles, consequences. Partial or chronic obstruction may fishhooks, bones and grass awns are among the be associated with varying degrees of dyspnoea, most common objects. Interestingly, the incidence chronic coughing, haemoptysis, halitosis and other of respiratory foreign bodies may be affected by symptoms associated with possible migration like season. For instance, in late summer or autumn, pneumonia, pneumothorax, pulmonary abscess or hunting dogs may be at risk of inhaling awns or pyothorax (Levitt et al. 1993; Tenwolde et al. 2010). foxtails when running through fields with their Tracheal and bronchial foreign bodies in the cat mouths open. Puppies or kittens can aspirate for- have been infrequently reported in the veterinary eign bodies associated with playing or teething literature (Levitt et al. 1993). We present a case of (as well as older with poor dentition). a cat that died after aspirating a beetle. According

Supported by the institutional funds of the Faculty of Veterinary Medicine, University of Veterinary and Pharma- ceutical Sciences Brno, Czech Republic.

198 Veterinarni Medicina, 63, 2018 (04): 198–202 Case Report https://doi.org/10.17221/8/2018-VETMED to the authors’ knowledge, this is the first report No heart murmur or additional heart sounds were of an aspirated insect in a feline patient. detected. Flow-by oxygen administration was com- menced. After initial stabilisation, an intravenous catheter was placed and blood for complete blood Case report count (CBC) and biochemical profile were col- lected. Results revealed leucocytosis (39.4 × 109/l) A 1.5-year-old female domestic shorthair with neutrophilia (32.9 × 109/l) and left shift (1.48 × cat, weighing 2.5 kg, was referred to the Small 109/l), hyperglycaemia (23 mmol/l), increased urea Animal Clinic at the University of Veterinary and (13 mmol/l), hyperproteinaemia (91 g/l), hyper- Pharmaceutical Sciences Brno, Czech Republic for albuminaemia (36.4 g/l) (albumin/globulin ratio: evaluation of an acute episode of dyspnoea. The 0.66) and hypokalaemia (3.1 mmol/l). The cat was owner noticed increased salivation and shortness of negative for feline viral leukaemia (FeLV) and im- breath since the preceding night over the course of munodeficiency (FIV) (SNAP FIV/FeLV Combo four hours after the cat had returned inside. After Test, Idexx Europe, The Netherlands). A single dose visiting their private practitioner, enrofloxacin, (4 mg/kg i.v.) of furosemide (Furosemide forte, BB oxyphyllin, and corticosteroids at unknown doses Pharma, Czech Republic) was administered and were administered seemingly without positive ef- thoracic radiographs were taken to rule out a wide fects. The cat was at that time nursing a three- range of conditions such as pneumonia, pulmonary week-old litter and was receiving the recommended oedema, pleural effusion and other causes of dysp- vaccinations and deworming. noea. On radiographs, the lungs appeared hyperin- At presentation, the patient appeared depressed, suflated with a diffuse bronchial pulmonary pattern dehydrated (approximately 6%), tachypneic (80 rpm), and normal heart size (Figure 1). Furthermore, on hypothermic (34.7 °C) and the mucous membranes the lateral view cranial to the carina a possible ra- were cyanotic. The cat exhibited a mild inspiratory diolucent mass effect of a few millimetres in size was effort that worsened with manipulation. Thoracic present. Echocardiography which was performed to auscultation revealed bilateral pulmonary crackles. rule out cardiac disease was normal.

(A) (B)

Figure 1. Thoracic radiographs of a dyspnoeic cat. A( ) Laterolateral view: small amount of air in the mediastinal space allowing visualisation of the aorta (*), cranial vena cava (**) and oesophagus (***). The heart silhouette has normal vertebral heart size index (7 v.) and seems elevated over the sternum (white arrow). Lung parenchyma shows a gener- alised pulmonary bronchial pattern. There is a radiopaque mass-like shadow on the tracheal bifurcation only evident in the lateral view (red arrow). (B) Dorsoventral view: the lung lobes extend to the edges of the thoracic wall and the caudal lung lobes reach the first lumbar vertebral body demonstrating lung hyperinflation (white arrows)

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Treatment continued in an oxygen cage with Entomology. The beetle was a summer chaf- correction of dehydration using lactated Ringer, er ( solstitiale), also known as the sedation (butorphanol as needed at 0.2 mg/kg i.m., European June beetle. Adults measure approxi- Torbugesic, Zoetis Manufacturing and Research, mately 10 millimetres in length; from April to June ), aminophylline (8 mg/kg i.v.) three times they can be frequently observed flying around tree a day (TID) (Syntophyllin, BB Pharma, Czech tops looking for a mate and they can often be found Republic), furosemide (2–4 mg/kg i.v. TID) and drowning in pools of water the following morning famotidine (0.5 mg/kg i.v. once a day) (Quamatel, (Balthasar 1956). The cat apparently tried to catch Gedeon Richter Plc., Hungary). The owner was or play with it and aspirated the beetle. informed about the presence of a possible mass or foreign body in the airways but due to finan- cial reasons could only agree to emergency laryn- DISCUSSION AND CONCLUSIONS goscopy. Anaesthesia was induced with propofol (2 mg/kg i.v., Norofol, Norbrook Laboratories Acute airway disease is a challenging situation Limited, Northern Ireland) and careful exploration in the emergency room. Several situations leading of the mouth, pharynx, larynx and cranial aspect to airway obstruction can be determined based on of the trachea did not demonstrate abnormalities. the history and clinical examination. In patients Therapy continued unchanged but the clinical sta- with marked inspiratory dyspnoea, upper airway tus worsened and the respiratory pattern was now obstruction or a condition affecting the pleural characterised by clear inspiratory effort. As the lack space preventing full lung expansion should be of a complete bronchoscopic examination meant diagnosed. Patients with predominantly mixed that prognosis was poor, the owner requested eu- dyspnoea (it is not common to observe patients thanasia and agreed to donate the body for nec- suffering exclusively from expiratory dyspnoea) ropsy. probably have lung or bronchial disease. Upper Necropsy findings. Significant gross post- airway obstruction may be accompanied by sneez- mortem findings included mild liver congestion ing, nasal discharge, wheezing, snoring, snorting and right ventricular hypertrophy, and the lungs or dysphagia. The present patient was an example exhibited small areas of atelectasis, hyperaemia, of a challenging situation, who at first presenta- small petechial haemorrhages and mild oedema. tion exhibited a mixed dyspnoea pattern, which A foreign body of approximately 1 cm in diameter, in combination with the radiographic and ultra- with a round shape, coated with a thick layer of sonographic findings led us to suspect lower air- white-coloured mucus, filling completely the lu- way disease (lung hyperinflation). However, during men of the trachea, was found approximately 2 cm hospitalisation, the dyspnoea developed into a clear cranial to the tracheal bifurcation. Strikingly, the inspiratory pattern. The administration of bron- foreign body was identified as a beetle (Figure 2). chodilators like aminophylline (although weaker At the site of the foreign body, the tracheal mucosa when compared with terbutaline, for example) be- was hyperaemic with small petechial haemorrhages fore any manipulation can help to prevent bron- and erosions. chospasm and coughing. Unfortunately, the use of

Figure 2. (A) Post-mortem view of the trachea showing hyperaemia and small haemorrhages. There is a foreign body obstructing the tra- chea. This foreign body is a Euro- pean June beetle (Amphimallon solstitiale). (B) A closer picture of the beetle’s morphology and its (A) (B) measurement (approx. 1 cm)

200 Veterinarni Medicina, 63, 2018 (04): 198–202 Case Report https://doi.org/10.17221/8/2018-VETMED laryngoscopy did not permit us to detect the beetle mals of similar body weight (Tenwolde et al. 2010). that probably already occluded air passage in the Also, a bronchial pattern with evidence of lung pa- trachea. Bronchoscopy should be recommended in renchymal over-inflation was present (generalised all cases where obstruction of the airways is present increased radiolucency, increased vascular pattern (Jones and Roudebush 1984; Nutt et al. 2014), but and elevated heart silhouette). Hyperinflated lungs in our case this was not performed due to financial are consistent with primary lung diseases such as constraints. The cat was then euthanised to avoid feline allergic bronchitis, parasitic disease and toxo- prolonged suffering. Depending on the experi- plasmosis among others. Hyperinflation may have ence of the operator the vast majority of foreign occurred due to the inhalation of air and it leads to objects may be removed endoscopically without decreased exhalation resulting in turn in the gradual the need for surgery. However, removal of foreign trapping of air in the alveoli which increases the bodies in the trachea may be challenging because radiolucency. In some instances, the air may escape such patients may have complications like hypoxia to the pleural or mediastinal space leading to pneu- or hyperthermia and such procedures are further mothorax or pneumomediastinum as observed in limited in most cats by the small diameter of the this case (Mackling effect) (Bay and Johnson 2004; trachea (Jones and Roudebush 1984; Levitt et al. Thomas and Syring 2013). One report found that 1993; Nutt et al. 2014). In these cases, a small- a common cause of pneumomediastinum in cats diameter flexible fiberscope (3 mm or less) with was general anaesthesia with endotracheal intuba- a working channel of 1.2 mm may be used to ex- tion and positive pressure ventilation, followed by plore feline airways. One veterinary study reported trauma and, less frequently, tracheal foreign bodies a success rate of 40% when using bronchoscopy (Thomas and Syring 2013); however, none of the for foreign body extraction in cats (Tenwolde et above could be confirmed in the necropsy. Other al. 2010). Using forceps with fluoroscopy to re- reported radiographic changes in foreign body aspi- move tracheal foreign bodies may be faster than ration are focal pulmonary to interstitial opacities, endoscopy and may thus decrease the duration of pneumothorax, pleural effusion or pleural thicken- anaesthesia; however, grasping the end of a foreign ing (Tenwolde et al. 2010). Pneumothorax can be body may increase trauma to the adjacent tracheal ruled out by determining the presence of lung tis- wall (Nutt et al. 2014). Nevertheless, such exami- sue on the edges of the thoracic cavity on both the nation should be accompanied by bronchoalveolar lateral and ventrodorsal views meaning that there lavage and cultivation, because foreign bodies often is no air surrounding the lung lobes, although the cause secondary bacterial infection of the respira- cardiac silhouette may be elevated (air trapping tory tract or migrate to other places in the body within the alveoli due also to over-inflation). There like the thoracic cavity, heart and abdomen, lead- is a significant association between radiographic ing to bronchopneumonia, pyothorax, abscesses or and CT lesions and the gross sites of abnormality. pneumothorax or haemoabdomen. Once foreign bodies reach a smaller bronchus they Alternative methods in cases when bronchosco- may be seen on radiographs as focal interstitial to py or fluoroscopy are unsuccessful or not possible alveolar infiltrates (2/3 of cases). In such situations, include computer tomography (CT), a presternal CT might be more accurate and time-efficient in tracheotomy to illuminate and view the object prior identifying foreign body location before interven- to grasping with forceps or a thoracotomy for di- tional therapy. A number of other CT abnormali- rect removal via thoracic tracheotomy (Levitt et al. ties resulting from the presence of foreign bodies 1993; Tivers and Moore 2006; Tenwolde et al. 2010). include pulmonary opacities, pleural effusion or Thoracic radiographs are useful to rule out foreign thickening of pleura, pneumothorax and the trac- bodies in the airways. In this case, the lateral view ing of the path of the foreign bodies (Schultz and showed a radiopaque shadow cranial to the carina Zwingenberger 2008). (Figure 1) that suggested the presence of a mass or In general, tracheal foreign bodies are occasion- foreign body. One study demonstrated that, in cats, ally seen in cats. Foreign bodies may be coughed up the most common location was the trachea or ca- or can pass beyond the tracheal bifurcation to lodge rina, and this finding was expected given the much deep within the bronchial tree; however, if they narrower luminal diameter in felines as compared are large enough, they often lodge at the tracheal with canine bronchi even when considering ani- bifurcation (Levitt et al. 1993; Tivers and Moore

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